Level: Advanced
Difficulty: Hard
Subtopic: Sleep and rest
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to sleep and rest….
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for nursing care related to sleep and rest. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Assume understanding without checking literacy or readiness.
C. Delegate all teaching without RN evaluation of learning needs.
D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale
Correct answer: D. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.